Healthcare Provider Details

I. General information

NPI: 1063092203
Provider Name (Legal Business Name): JACK PYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S 11TH ST
LAKE WALES FL
33853-4203
US

IV. Provider business mailing address

243 C F KINNEY RD
LAKE WALES FL
33859-7545
US

V. Phone/Fax

Practice location:
  • Phone: 863-676-1433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number181541
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: